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The Royal College of Psychiatrists Improving the lives of people with mental illness

CR190. Consensus statement on high-dose antipsychotic medication

Price: £0.00

Approved: May 2014

Published: Nov 2014

Status: current

Number of pages: 58

Review by: 2019

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This report is online-only.  There are no print copies to buy.

This report reflects the consensus views of a group of clinicians on the risks and benefits of high-dose antipsychotic medication for a range of clinical indications for which antipsychotic medication is commonly used in psychiatric practice. For each of these indications, the members of the Consensus Working Group took account of the evidence from the published literature and their clinical experience, and considered the clinical implications. While there is little convincing evidence that off-label prescription of doses of antipsychotic medication above the licensed dosage range has any therapeutic advantage in any clinical setting, there is clear evidence for a greater side-effect burden and the need for appropriate safety monitoring. The key recommendation is that any prescription of high-dose antipsychotic medication should be seen as an explicit, time-limited individual trial with a distinct treatment target. There should be a clear plan for regular clinical review including safety monitoring. The high-dose regimen should only be continued if the trial shows evidence of benefit that is not outweighed by tolerability or safety problems.


This report replaces an earlier report, CR138 (of the same title), from year 2006.



  • Membership of the Consensus Working Group
  • Abbreviations
  • Executive summary
  • Definition of high dose
  • Prevalence and nature of high-dose antipsychotic regimens in clinical practice
  • The pharmacological basis for high-dose antipsychotic prescribing
  • Why do clinicians prescribe high-dose antipsychotics?
  • First-episode psychosis
  • Acute psychotic episode
  • Relapse prevention in schizophrenia
  • Acute violence and emergency tranquillisation
  • Persistent aggression
  • Schizophrenia failing to respond to standard antipsychotic regimens
  • Dose-related side-effects
  • Extrapyramidal side-effects
  • Neuroleptic malignant syndrome
  • Cardiac side-effects of antipsychotics
  • High-dose antipsychotics and cognition
  • Potential gender and ethnicity factors and high-dose strategies
  • Withdrawal of high-dose antipyschotics
  • Off-label use of a licensed medicine
  • References
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